Sunday, September 28, 2008

Alphabet Soup

To many, in conjures an image of a trusty elder statesman of medicine, a healer, a researcher, a teacher and therapist of all things related to diseases of the human body.

It comes from the Latin, Medicinæ Doctor, meaning “Teacher of Medicine.” In the US, it is the first professional degree for physicians while in other countries, such as Germany or England, it is a higher doctoral research degree resembling the PhD (Philosophiæ Doctor, meaning "teacher of philosophy").

For reasons that are unclear to me, physicians also occasionally include other letters beyond the “MD” in their name. These add little to the MD descriptor, other than to define a professional society with whom the doctor associates themselves. For instance, I am a Fellow or the American College of Cardiology, and have “FACC” sometimes appear on my stationary. I never write this designator when signing my name, but I know my referring colleagues in medicine want to know I’m one of the gang, so it appears there. It also implies that I pay my dues to the American College of Cardiology which also serves as our political and advocacy branch of our subspecialty.

I find patients rarely understand what these letters mean, for there are many such designations. FACS means a Fellow in the American College of Surgeons, a surgical professional group, and FACP means Fellow of the American College of Physicians, a professional group of internists, for instance. Some people, like cardiologists who have first been internists before becoming a cardiologist, like to add both the FACP and FACC designator after their name. Providing, they’ve paid the fee and been vetted by the respective professional groups, no one seems to mind. A signature line becomes virtual alphabet soup as doctors sign their name “John R. Smith, MD, FACP, FACC.”

Big deal.

Regrettably, these initials are nothing more than a narcissistic exercise of self-aggrandizement, rather than meaningful milestone of additional education or skill. Further, in our zeal to differentiate ourselves from our less-specialized colleagues, they have promoted the fragmentation of our profession as a collective bargaining body in matters of public policy important to physicians collectively. The alphabet soup conveys no indication of additional qualification of the physician, only that they have paid for the privilege to add these to their names, have a valid license, and know a few colleagues in their same subspecialty club.

Importantly, these letters do not imply an individual is “board certified” by any one of the 24 Member Boards that make up the American Board of Medical Specialties. Within each specialty like Internal Medicine are often other subspecialties, like gastroenterology, rheumatology, cardiology or cardiac electrophysiology. In total, there are presently 145 specialties and subspecialties in which a doctor can become “board certified” and 145 ways we fragment our negotiating power on Capital Hill as each group fights for their own interests. It’s also 145 ways we confuse the public (and each other), 145 ways we lose our focus on the bigger picture of healthcare in America, and 145 ways that third parties can play us off one another as they forward their agendas over ours.

In effect, our sub-specialized egos and alphabet soup have neutered us as effective voices in healthcare reform.

Worse still, while “board certification” defines an important level of competence that should not be undervalued or disrespected in terms of the expertise required to achieve such certification, the term itself has been confused with the sponsoring professional society memberships' alphabet soup and has obscured our ability to protect this important credentialing designation.

17 comments:

Anonymous
said...

while i disagree slightly on what board certification guarantees from a patient perspective in terms of clinical care, i fully agree that we have way too many meaningless divisions in our once highly esteemed profession.

Nice blog to discover. Hey I was wondering, is it possible to gauge how screwed up my arteries are if I tell you I'm 26, I smoked for 12 years, light smoker, 5 cigs a day, equates to three 'pack years', the term often used in studies referring to pack a day guys, I gave up cold turkey, I ate like a moron from about 18-25 (as soon as I was responsible for my food and not my mom), I ate like Quarter Pounder burgers like twice weekly, I didn't drink much, I had some people drop dead on me, no excuse I know, but for a few years I wallowed in it, and I sort of abused my 'feel good centers' with cigs and fatty food, in my recent years I've wised up, but the more I read the more I am terrified of some old lump of cholesterol breaking loose and traveling some place and killing me. I guess what I am asking is just how many years does it take to screw yourself up, I read about some british kid whose mom fed him sausages every day of his life and he died of a heart attack at 19 years of age, I'm like 20 pounds overweight, used to be 40 pounds overweight, I've in the past been put on some dangerous so called 'medications' from the clowns in psychiatry for my alleged 'biological brain disease' 'depression' after some people died in my life, but I'm off that neurotoxic garbage now, having realized you'd have to be a clown to agree you had a 'brain disease' when the idiot telling you that you have it possesses, well, lets see, ZERO diagnostic biotechnology, I guess I got hoodwinked, like millions more, in the past these clowns had me on the billion dollar class action lawsuit magnet 'Zyprexa' which caused all sorts of metabolic disorder, and totally made me put on weight, half of which I have lost. Basically, I've been under siege from my own stupid love of cigs and burgers, and the intellectually dishonest snake oil pushing clowns in the pathetic pseudoscience of psychiatry. I'm on the right track now I know, I am well on my way to restoring fitness and most respects, I guess what I want to know is, the damage that was done, and there must have been a little, should I be in mortal fear of it? I mean, can you turn into the healthiest dude in the world and be like 46 and have some plaque that was laid down when you were 24 bust off and cause a stroke or something. I have no history of heart disease or cancer in my family, some longevity in the women actually (i'm male). I have an EKG and a liver and kidney function test six months ago and everything came back ok, the miserable guesswork psychopharmacology they inflicted on me reduced my liver function by a quarter to a third at one stage. I'm so mad I ever trusted these clowns, they've hitched their wagon to the hard sciences like yours and despite the lack of a single piece of diagnostic biotechnology orchestrate massive neurological perturbment, and not just the brain, all major organ systems, it's sheer darts at a board, its delusion in itself. I personally have been put off your whole profession almost just sheerly due to the fact you would even allow these clowns to join your ranks, but alas, I deeply fear ever depending on a doctor for a thing ever again in my life. I want to know, from a cardiovascular perspective, not to 'diagnose' me, but just if you could generally put it out there.... could seven years in your late teens early twenties, of stupid living and toxic drugs set you up for a big fall? I've seen those 3d radiography scans on TV or whatever they are, should I get one of them. I am literally terrified I might have some occluded something or other. When I was a kid, no one ever even taught me about arteriosclerosis, maybe in passing in science class, but never was it hammered in the way I've hammered it in myself now that I'm 26, I read a little online about and it just literally terrifies me. As I said, the weight continues to come down, there is no smoking and hasn't been for like almost a year, it was 'light' but it did go on since I was 13 years old to 25 years old... family of smokers, its embarrassing now I know, and no history of anything, and I did have a slightly raised cholesterol back when I had a test when I was on the filthy neuroleptics for 'brain disease depression'... Now, as I get older, the more I know I am going to feed my children the strictest diet in the history of the civilized western world, I wish no one had let me anything of my choosing until several months ago when I wised up. I like your blog, and I hope you can please give me a brief word to the wise, allay or confirm my fears, or just let me know, if I am being paranoid. I suppose there are guys out there that have been 100 pounds overweight and lost it and lived a long and safe life, and guys my age who have been mired in heroin and alcohol the whole time, but I just have this fear from reading all this stuff online, and I just guess it would be real nice of you if you could just say a word or two on this situation I find myself in. I don't know whether its because I had three members of my family die suddenly in recent years in accidents etc, that I have this heightened dread, but I guess you'd be pleased to know I am one of those guys that is so terrified, sheer horror and terror, of ever having his arteries coated all in fat and plaque, that it is just enough to give me the willies and never eat burgers or cheese or smoke again. Man O Man, I don't know, I just, I probably sound real silly, I'm just in the dark about how much damage I may have done. I was a real healthy kid up til about 18 years of age, despite my slight smoking, and I can say I haven't enjoyed my 20s one bit so far, due to many factors, but I have finally got my act together in several respects, I just have these lingering fears I suppose. Kind Regards, Bill

Great post. When I passed my boards, I looked into becoming FACS, thinking it was some sort of elite designation. Then I discovered what was required: a couple letters from friends already in the club and your checkbook. I think I'll pass. MD is good enough for me.

Please tell me I'm missing something. There can't be grown men and women in the world paying money for 4 letters behind their name. I thought these things were granted for academic achievement or something.

Grown men spend much more on even more trivial things than they do for professional society dues.

Fellowship status does represent something, it means at a minimum that you have become board-certified in your ABMS-recognized specialty. As there is no way to designate board certification status in a title, something which does represent an academic and occupational achievement (practically speaking, it could be regarded as a masters degree, which was actually awarded in some specialties at one time), fellowship abbreviations have taken that role.

No one forces anyone to join or to use those initials and you can be just as accomplished without them, but to say they represent little more than a club that your professional friends invite you to join is just not the whole truth.

Your last comment is a very important distinction and you should correct your statement in the original post. "Importantly, these letters do not imply an individual is “board certified” by any one of the 24 Member Boards that make up the American Board of Medical Specialties." Thank you Anon 7:30 for your comments.

If FACC as a designation requires board certification (I always thought it did, but couldn't find anything on the ACC web site to back this up), then this designation does carry some tangible meaning.

I've always told my patients that FACC served as some type of "seal of approval" that may help distinguish those genuinely committed to the profession of cariology (and related subspecialties). Clearly, it does not ensure quality, but it does help filter out those who "dabble" in the care of cardiac patients without the proper education and committment. There is clear data that quality measures such as guideline adherence are better followed by cardiologists than non-subspecialists.

Since most physicians don't market or advertise their board certifications (except in frames in their offices), a patient can use the FACC designation to quickly determine who has tackled this legitimate achievement.

On the other hand, mere membership in the ACC really doesn't and shouldn't carry any kind of weight beyond a desire to support the goals of that organization. Membership in the ACC does not ensure skill in caring for patients any more than membership in the NRA makes one a marksman.

These organizations provide legitimate services to the interest of the public such as public education, guideline authorship, and political lobbying. They need money to operate.

It's certainly any doctor's choice to "opt out."

Do you think we'd all be better off, though, without these professional organizations??

From a collective bargaining position of specialties, as well as an attempt to maintain competency and education in our ever-changing subspecialty fields, I think the organizations are very helpful. Unfortunately, in the fight for medicare reimbursement, there are lobbies for both sides (generalists vs. specialists) that fight for their independent interests rather than working collectively to help both groups.

I am a member of ACC, but not an MD, so you definitely don't need to be board certified to be an ACC member.

We have an egotistic chief of surgery who has so much alphabet soup after his name that it takes up an entire line of script below his name. I literally laughed when I saw his business card. An MD colleague and I could only figure out about half of what the soup meant. I'm sure that most patients would have no clue.

A similar critique could be applied to NPs. Unlike CRNAs, NPs do not have one lobbying body, thus our political power is diluted. CRNAs have a very strong lobby and are much more effective at influencing policy (whether you view it positively or not, they are quite effective).

Interesting. I'm an attorney, and attorneys usually do not use "J.D." after their names. For one thing, anyone with a law degree can use "J.D.," even if they never passed a bar exam or practiced law. To indicate on your business card that you are a practicing attorney, you would normally just put the name of your law firm, or "attorney at law." If you work for the government or a corporation, you would give your job title. For example, anyone who is general counsel or assistant general counsel or the like is impliedly admitted to practice because that is a requirement for those jobs.

What I'm getting to is that it is considered kind of ostentatious, even low class, for an attorney to list his degrees after his name, in most situations.

I'm still confused. I thought that those who complete fellowships must take & pass certifying boards to carry the "Fellow" title. Your post has led me to realize that I base this on little more than hearsay & assumption (approximate level of evidence: 42). Guess I've been hitting the q2 call a little too hard lately. Thanks if you can clarify the matter for me, a still-green med student.

Wow, that's disappointing. This is the sort of thing that sometimes leads me to forget that many individuals strive for high ideals. I'm inclined to avoid (or avoid referring patients to) anyone who knowingly adopts the title of Fellow without the training & certification to support it. Thanks for drawing my attention to this phenomenon & answering my question.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.